Medial Patellofemoral Ligament Reconstruction Using All-Soft Suture Anchors for Patellar Fixation  Justin L. Makovicka, M.D., David E. Hartigan, M.D., Karan A. Patel, M.D., Sailesh V. Tummala, B.S., Anikar Chhabra, M.D., M.S.  Arthroscopy Techniques  Volume 7, Issue 3, Pages e231-e237 (March 2018) DOI: 10.1016/j.eats.2017.08.075 Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 1 Lateral (A), medial (B), and end-table (C) views of operating room setup in preparation for medial patellofemoral ligament reconstruction. The patient is supine with the knee at 90°. The post and sterile draping can be set up as per the surgeon's preference. Arthroscopy Techniques 2018 7, e231-e237DOI: (10.1016/j.eats.2017.08.075) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 2 Lateral (A) and medial (B) views of outlined patellar and femoral incisions, along with standard anterolateral and anteromedial arthroscopy portals. A longitudinal line is drawn along the medial border of the patella with the knee in extension. The knee is then flexed to 90°, and a longitudinal line at the location of the medial epicondyle is drawn parallel to the first line for the femoral incision, both approximately 3 cm in length. Arthroscopy Techniques 2018 7, e231-e237DOI: (10.1016/j.eats.2017.08.075) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 3 A diagnostic arthroscopy is performed addressing all concomitant pathology with particular attention paid to the patellofemoral joint pathology, alignment, and need for treatment. An arthroscopic view of the patellofemoral joint with visualization of the attenuated medial patellofemoral ligament (MPFL) can be seen. Arthroscopy Techniques 2018 7, e231-e237DOI: (10.1016/j.eats.2017.08.075) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 4 Once the medial patellar incision is exposed bluntly down to the retinaculum, it is incised in line with the skin incision approximately 2 to 3 mm off the border of the patella (A) and a T-incision is then made at the one-third–two-thirds junction of the proximal patella (B). Care must be taken not to incise the joint capsule. Arthroscopy Techniques 2018 7, e231-e237DOI: (10.1016/j.eats.2017.08.075) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 5 (A) The proximal anchor site is drilled in the trough at the one-third–two-thirds junction of the proximal patella, and a 1.8-mm Q-Fix anchor is placed at the proximal anchor site. (B) A second 1.8-mm Q-Fix anchor is placed 0.75 cm distally to the first. Arthroscopy Techniques 2018 7, e231-e237DOI: (10.1016/j.eats.2017.08.075) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 6 Once the graft is thawed and cut to the appropriate length, the long limb of each suture anchor is whipstitched to 1 end of the graft (A) and the short limb of the suture is then pulled to cinch the graft into the bone trough (B). (C) After both ends are fixed and tied into the trough, a looped graft with 2 limbs on the patella is created, simulating the anatomic insertion of the native medial patellofemoral ligament on the patella. Arthroscopy Techniques 2018 7, e231-e237DOI: (10.1016/j.eats.2017.08.075) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 7 (A) Once the femoral incision is dissected down to the medial epicondyle, the knee is flexed to approximately 90° and fluoroscopy is used to isolate the Schöttle point on a perfect lateral radiograph. (B) This point (star) is located approximately 1 mm anterior to the posterior cortex of the femur, 2.5 mm distal to the posterior origin of the medial femoral condyle, and proximal to the posterior point of the Blumensaat line. Arthroscopy Techniques 2018 7, e231-e237DOI: (10.1016/j.eats.2017.08.075) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 8 In approximately 30° of flexion, tension is pulled on the graft through the lateral side and the graft is fixed into place with a BioComposite interference screw 1 size larger than the diameter of the tunnel. It should be noted that during tensioning, a Kocher clamp is placed underneath the graft at the medial incision site to prevent over-tightening. Arthroscopy Techniques 2018 7, e231-e237DOI: (10.1016/j.eats.2017.08.075) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions